Learning collaboratives help health centers improve primary care

A Commonwealth Fund study reports that while community health centers deliver primary health care to much of New York City’s low income population, the design and delivery of health care services at the centers can be made more patient-friendly. There often are delays in access to care, according to researchers Pamela Gordon and Matthew Chin, making it difficult to get an appointment. Inefficiencies in patient flow also are common, they wrote, resulting in office visits that are needlessly long.

To help the community health centers improve, the nonprofit Primary Care Development Corp. (PCDC) implemented a learning collaborative model at four New York City community health centers. "Using PCDC’s methods, each center made dramatic improvements in key operations: getting patients in and out of the center quickly; offering appointments with the patient’s primary care provider on demand; enhancing revenue collections; and attracting and retaining patients," Ms. Gordon and Mr. Chin wrote.

The researchers said a successful implementation model is based on clear, simple, and effective principles, with five strategic principles applying to all collaboratives:

1. Build a high-functioning team.
2. Cultivate leadership support and involvement.
3. Track data and map the process from the patient’s perspective.
4. Open lines of communication.
5. Use the expertise of PCDC coaches and program leaders.

The four models are shown here:

Redesign the patient visit program. The redesign reduced the cycle time 40% from 68 minutes to 41 minutes, with a 58% increase in productivity from 2.85 patients per hour to 4.5 patients per hour. Ms. Gordon and Mr. Chin said the Jerome Belson Health Center serves a developmentally disabled population, which made the task of reducing patient cycle times even more challenging than usual. "Even so," they said, "the principles of redesign successfully transformed an overcrowded waiting room that was far from user-friendly into an environment where the patient comes first, and providers and staff are highly productive." Redesign principles include: Don’t move the patient; eliminate needless work; increase clinician support; communicate directly; exploit technology; monitor capacity in real time; get all the tools and supplies you need; create broad work roles; organize patient care teams; start all visits on time; prepare for the expected; and do today’s work today.

Redesign the patient visit process. At Union Health Center, PCDC said the key to reducing backlog and meeting demand was to measure the third-next-available appointment time. Union patients commonly had to wait as long as 15 days before they could schedule an appointment. After the seven-month redesign, patients received appointments in one day or less, a 93% decrease in appointment scheduling time. And the patient no-show rate dropped as staff and patient satisfaction levels increased. Redesign principles include: Do today’s work today; work down the backlog; reduce appointment types and times; develop contingency plans; reduce demand for visits; and balance supply (provider time) and demand (patient visits) daily.

Improve efficient revenue collection. The Brownsville Multi-Service Family Health Center undertook an effort to collect revenues efficiently through the entire collection process. The center serves a low-income community living predominantly in public housing. Its challenge was how to sustain revenue while meeting its clients’ overwhelming needs. As a result of changes made through the learning collaborative process, average weekly cash receipts increased by 46%. Reimbursement per visit rose 55%, from $78 to $121. Ms. Gordon and Mr. Chin said the case study also documents how the work of the learning collaborative improved employee morale and encouraged high performance throughout the organization. Another significant result of the effort was the adult medical care unit increased patient visit volume by 5% after several years of decline. Ten revenue maximization principles identified in the redesign are: Do it right the first time; collect money due at the point of service; eliminate lag times between service and billing; manage claim rejections; redesign bad processes; encourage teamwork; leverage technology; share data; establish good internal control systems; and maintain appropriate staffing.

Improve marketing and customer service. This case study provided insight into how the South Bronx United Health Plan (UHP) health center adapted highly targeted marketing practices and increased and sustained patient volume in a very competitive environment. UHP had conducted an extensive media campaign for a new facility, which had generated much interest. But it realized it needed help in understanding the process of marketing without relying on expensive consultants. UHP enrolled in PCDC’s Marketing and Customer Service Learning Collaborative. PCDC helped UHP understand the importance of a two-pronged approach to community outreach — creating an in-house marketing division able to customize outreach efforts to narrowly defined populations ,and creating and maintaining employee and customer satisfaction. Marketing principles that were applied included situational analysis, marketing objectives, marketing strategies, marketing tactics, and evaluation. Eight customer service principles are leadership commitments, service defined from a patient perspective, service standards, continuous improvement, internal communication, ongoing communication, reward and recognition, and patient satisfaction measures.

Re-engineering patient throughput, provider paneling, and patient scheduling is at the heart of the PCDC collaborative approach, according to Ms. Gordon and Mr. Chin. "Overhauling these processes is the key to enhanced health care success, provider and customer satisfaction, and operating efficiency," they said.

"The end result is the delivery of patient-centered care. Patients are very satisfied with these changes. They are able to access their primary care provider on the same day instead of next week or next month and are able to complete the visit in less than one hour instead of the typical two to four. For staff, the days run more smoothly. Employees are able to work at their highest level. People are able to go to lunch and the clinic closes on time. Ultimately, clinicians have better support for their work and can focus on building relationships with patients," the researchers explained.

All PCDC collaborative participants use the same collaborative model, which has three different stages. At each stage, elements of the collaborative are introduced and implemented.

PCDC cautioned, however, that the path through the stages is not linear but rather is more like a spiral, with each collaborative stage overlapping the stage that comes before it and also the one to follow. The work of one stage spills into and informs the work of the other stages.

"Rather than following directions that take them from point A to point Z," the researchers said, "participants also move forward in an elliptical path that is marked by their growing awareness of what works and what does not what at their particular health center. With this awareness comes an ability to use tools to make and sustain permanent changes in productivity, efficiency, and attitude."

The first step of the pre-work stage is to form a team from multiple disciplines within the center and start to gather the baseline patient tracking data that will be the basis upon which all improvements are measured. Teams participate in three learning sessions facilitated by PCDC staff and nationally recognized leaders in the collaborative field being worked on.

Two action periods take place between the three learning sessions. During the action periods, teams run through rapid tests of change in highly controlled situations. These sessions use the plan, do, study, act cycle method that leads to a final redesign model that is completed over a period of three full days. Once the process is finalized, the methods are passed on to nonteam personnel.

Transform how people work

According to the evaluation, collaboratives do more than simply fix particular operations problems. They transform the way people work, expand the boundaries of responsibility, and instill a sense of accountability to patients.

PCDC contended it is very important to engage health center leadership in the process. Organizational leaders are inspired when they experience the change process through the perspective of their newly motivated staff, officials said. Senior leadership must be involved if the collaborative team is to be successful over the long run.

Teams with weak organizational leadership frequently reach their goals. But without consistent, engaged leadership, few teams can sustain success.

PCDC said it is difficult to tell if gains delivered by learning collaboratives can be maintained. Data collection often stops shortly after a collaborative ends, and there is no strong evidence that supports sustainability of the gains long-term.

Sustaining gains is a problem

"PCDC has often observed that when a collaborative ends, there is little focus on sustaining the initiative," the report said. "Inevitably, the improvements do not last. Teams are consistently able to make breakthrough changes and completely overhaul existing processes, but if they do not build in accountability for ongoing measurements, the improvements are lost. . . . Health center leaders must recognize that they should take steps to preserve these gains, even after the collaborative concludes."

Ms. Gordon and Mr. Chin said a model familiar to many people that is able to extend involvement without creating dependency is Weight Watchers. The program is based on three simple principles — eat less, move more, and drink eight glasses of water every day. The principles are easy to understand, but often quite difficult to follow.

Likewise, principles for redesigning the patient visit and advanced access are simple and easy to understand, but hard to follow. For redesigning patients’ visits, the principles are: Don’t move the patient; eliminate needless work; increase clinician support; communicate directly; exploit technology; monitor capacity in real time; get all the tools and supplies you need; create broad work roles; organize patient care teams; start all visits on time; prepare for the unexpected; and do today’s work today.

For advanced access, the principles are: Do today’s work today; work down the backlog; reduce appointment types and times; develop contingency plans; reduce demand for visits; and balance supply (provider time) and demand (patient visits) daily.

Ms. Gordon and Mr. Chin suggested that those who participate in a learning collaborative need ongoing support after the process every bit as much as Weight Watchers participants do. "Perhaps, the problem lies in the way a collaborative is described as a framework for learning a new method," they wrote.

"Instead, it should be recast as a process used by a community of participants to make lifelong behavioral changes. Transforming the dismal patient experience into one that is satisfying for both patients and health care workers takes effort. Health centers must permanently change their individual and collective work behaviors: the way they treat patients, the engineering of work processes, the ability to work together in teams, and the use of technology. Problems arise because an organization’s leadership often views the collaborative journey as a consulting engagement. Leaders demand solutions that require little effort or time on the part of management. Despite their health center’s participation in the collaborative, many leaders never learn how to initiate and sustain change," the researchers said.

PCDC said it understands that gains achieved through the collaborative process are fragile and are almost certain to unravel if left unattended because the organization’s transformation is incomplete.

The solution, it noted, is to make a health center’s leadership responsible for anchoring the new culture in the organization.

First, management should communicate to employees frequently and clearly that the new methods and new ways of measuring results are not part of the organization’s culture. And second, management should implement clear, consistent systems for defining, measuring, and sharing key results. "These two actions by management form the foundation of a strong organizational culture," the report said.

(More information is available from The Commonwealth Fund on-line at www.cmwf.org.)